Errors 'frequent' in intensive care

17th March 2009

Intensive care units around the world frequently inject patients with the wrong medications, with 19% of patients the subject of a single error, a study shows.

The multinational, European prospective study that assessed the frequencies of administrative errors in injected medications in intensive care units (ICUs) also made suggestions about preventative measures.

The finding showed that injected medications were a major safety problem in ICUs.

However, the researchers said that the risk of injection errors can be reduced by implementing a comprehensive strategy that checks for errors and takes reports of them.

Many European nations were included in the study, including France, Italy, Austria, and Portugal.

Researchers monitored errors in 1,328 patients in 27 countries over a 24-hour period in January, 2007.

Two ICUs in the US were also included, adding the reports of 50 patients to the mix.

Andreas Valentin of Rudolfstiftung Hospital in Vienna, Austria led the study.

He and his multinational team found 861 total errors involving 441 patients receiving injected medications in 113 total ICUs.

The study found no errors in 67% of all patients, 19% experiencing one error, and 14% experiencing two.

Though most of the errors caused no harm, 15 caused permanent death or harm to 12 patients, or 0.9%, half of which involved one or more medical trainees.

About 20% of ICU staff blamed their errors on oral communication problems, or that their prescriptions were violations of protocol.

In addition, ICU staff described workload, stress and fatigue as contributing factors in just under a third of all cases.

The most common causes of errors were a wrong administration time and a missed medication, with 356 and 259 cases.

Some patients were also given the wrong dose of a drug, the wrong drug entirely, or were injected through the wrong route.

ICU staff also blamed recently changed drug names and written communication problems with doctors for their errors.

The risk of an injected medication error increased significantly with a higher level of patient illness, the occurrence of organ failures in patients, higher rates of drug injections, larger ICUs, and more patients per nurse.

When a routine of checks that nurses could do when their shifts were finished existed, the number of risks was lessened.

Researchers said that the results of the prospective study point to the fact that this is a weak point in the management of ICUs.

They said that the injection errors at the administration stage are a common though reducible safety issue in ICUs.